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Uh once it starts, there you go. Yeah. Okay. Okay. Hello. My name's Rohan. I'm a third year medical student at Imperial and today we'll be delivering the session on history taking. Um I've included my email on the last night. So if you got any questions about it, then feel free to email me. Um, but we'll kind of be going uh through the history taking station. This is tailored for the CPA exam in year two. Uh and hopefully the session won't take too long. Um But as if you have anything, any questions or anything, you can pop it in the chat. Uh and I'll be happy to answer them as we go along. So in terms of the uh contents of what to kind of expect we're going to go through what the exam itself is actually like in terms of its length, um a basic kind of structure that you can use um as well as then looking at a systems review and then doing uh giving some kind of tips and tricks on how to actually approach the examine. Hopefully they'll make it a bit easier for you guys. So in terms of the exam itself. So you have an actor and an examiner. Um, they'll be an 11 minute station. Um, and outside when you're having, you should have some reading time outside of the station. Um And they might ask you to focus on certain parts, parts of the history. Um So I remember last year for us, they told us, um to focus more on the lifestyle factors. Um So things like smoking, alcohol, drinking, um and they told us not to focus on a systems review, but that could be different for your year. So always just kind of pay attention and make sure you read um, the sheet that's outside the station just so that you're aware of what to expect when you're going in and you've only got a minute reading time. Um, so just make the most of it okay. So, um, in terms of the introduction, consent will go through it. But before we do, does anybody want to have a go themselves, how you'd introduce yourself to, uh, to a history taking station or even to, you know, an examination, you should have your, uh, introduction should be pretty kind of standard. Does anyone would feel brave enough to, um, you do, you can pop it in the chat if you want. How would you introduce yourself? Good to you too. Because then that way I can also give you kind of feedback and help you tailor it to uh to this exam. Anybody economic mute. It doesn't, I don't buy it, give it a few more seconds. Uh Okay. Um So, so we'll move on then. Uh So basically this is your main introduction. Um So obviously you wanna net your full name. Um You were also your second year, third year medical student, um or second year in your case. Um And the reason for why you're talking to the patient. So, um you'd want to say something, would it be uh uh I'll go through that later, but you ought to want to mention the expected time and also, you know, obviously get consent from the patient. So say, would it be okay with you? Um And always, always, always make sure you check the name and date of birth, the patient because you want to make sure you're speaking to the right person. Um So for me, you might say something like hello. Uh My name is Johanna half tab, I'm a second year medical student at Imperial College. Uh Today, I've been asked to speak to you too about um what's brought you in to see the G P or what's brought you into hospital? Um And then again asked, would it be okay with you? And then you always want to make sure that they'll get to be able to see, know that they'll be able to see the doctor afterwards. Um So you just want to reference that uh there as well. Um And yet name and date of birth patient. If you take anything away from this, always check this because this is actually like uh mark point in the exam. Um So even if you, you know, even if you really flop the rest of the history in the introduction consent, there's there's marks for that. Um So make sure that you kind of practice this. Um And this is the kind of something you can do yourself just um looking yourself in the mirror or just make sure you're practicing it and incorporating all of these aspects. Okay? Um So, in terms of the presenting complaint, uh you want to think about ways to kind of open up the conversation and you might hear this thing called the Golden Minute, which is basically where you just like let the person speak for a minute about what's going on, but uh to prompt that you might say something like what brings you in today or what can we help you with today? And you want to try and be as um open as possible. Uh And not, not trying to ask too many closed questions. Um And actually, that's another thing with mark schemes. Um They may include you asking a variety of open and closed questions, that's just something to be aware of there. Um So, yeah, as I've said, allow the patient to kind of talk. Um and they'll often give you a lot of the clues that you're looking for. Uh in terms of your history taking so onto the, with this, the history presenting complaint is your main bulk of your history. Um And it'll vary according to the symptom with what with which the patient's presented with. So, if it's something like pain, um So you've, you'll want to do Socrates. Have you all heard of Socrates? Just put it in the chat if you have or haven't? So I know how much kind of explanation I need to do. Um No, okay. That's fine. We'll, we'll go through that. I might have a slide on it later. But if I don't, then um I'll make sure I go through that. Um And if it's something else, which is kind of like breathlessness, um then you can use Socrates as a base. Um And I'll just talk through what um Socrates is, has basically pneumonic uh for remembering questions to ask about uh a person presenting with pain. So you might have something like chest pain, abdominal pain, um uh back pain, any kind of, any kind of pain you want to do Socrates. Um And in terms of what it stands for. So the first s it's for site. So that's the best way of kind of ascertaining this is, can you, can you tell me where the pain is or can you show me where the pain is? Um So for example, if they say kind of here, that's kind of the epigastric region. Um So you want to be able to quantify where the pain is because that will help you in your differential diagnoses uh which is onset. So you want to know how suddenly the pain came on? Um So was it sudden onset onset? Was it gradual, did it gradually get worse? Uh C is characteristic? So you want to try and get them to describe the pain in their own words? Um So you could, you can say something like, oh, could you, um, could you describe the pain for me? Uh They might uh describe it as dull, throbbing, sharp. Um, and sometimes, uh they, they don't really know what you mean when you say, describe it for me. Um So you can give them prompts. Um but it's best not to because then you're kind of leading them into it and they might, they might just say go with whatever you say. Um So that's c so are, is radiation. So does uh the pain go anywhere else? And you want to be specific? Um in that you, I want to inquire about that pain specifically because they might have, you know, they might have other conditions that give them pain as well. But you want to say with this pain, uh the pain go er anywhere else and don't use the word radiate because that can confuse people. Um And then with a, you want to ask about associated symptoms. So, uh for chest pain, for example, you might ask about nausea, vomiting, sweating, all these kind of symptoms suggestive of, uh, my cardio infarction, a heart attack with, uh, ti you want to ask about the time course. So is there any specific time at which the pain gets better or worse or is there, uh, how does it vary throughout the day and e is exacerbating factors? So, anything that makes it worse? Uh, and then with that, you also have to remember anything that makes it better. So it kind of comes as a pair and s is severity. So if you had to write the pain on a scale of 0 to 10, where zero is the kind of least no pain basically attends like the worst imaginable pain. Where would you rate it on that scale? Um So that Socrates basically in a nutshell, uh I went through that quite quickly, but if you've got any kind of questions on that, then just pop them in the chat and I can answer them. So that's your main kind of reference for pain. But if it's something else, then you can still use that as a base. Um And you just, you just try and adapt it. Um And we'll go through kind of some examples later. Uh So in terms of other questions you want to ask, uh within this section of the history presenting on that, you want to ask whether something like this has ever happened before because then that can give you a kind of a better picture of what's going on. And again, has it been getting better or worse? And if it's getting worse, um, then that's quite a bad sign and that's a sign that might need more urgent treatment. Uh, I have got a slide on it. Okay. There we go. So that's um, kind of a slide. And Socrates. Um, they're so, which I've kind of talked about already. Um, again, if you've got any questions, just pop them in, in the chat, I've got, yeah, I can't see any questions in the chat. Okay. Okay. And another point here is that you can actually um ask some kind of system related uh questions uh as part of this kind of associated symptoms, bit of Socrates. And we'll go, we'll go through that later and after you've done Sokrati because it can be quite a lot, they're telling you everything about what they presented with. So you, it's a good place to include uh an interim summit summary. Then after you've done that, you want to go into the past medical history. So this is kind of, can I ask a lot of questions about this? But these are the kind of name for that would say the most important. So, do you have any other medical conditions, anything you see your GP regularly for any previous admission's to hospital? Um and any previous surgeries. Um And another thing is to kind of mention, uh you might mention something like kind of high BP. Um, because often people don't think that's really a kind of a medical condition. They just think that's the thing that they won't associate it. Um, so that's just kind of something to another one to add on. Um, but these are the kind of main, if all that I'd say are the most important ones and you should be able to get most of your kind of information out from here. Um, and also from this, you might get an idea as to what kind of medication they might be on as well. Um, but you'll, you'll inquire more about that in, in, within the drug history. Um, so in terms of, so we've got our structure, we've done our presenting complaint, history, presenting complaint, we've done our, the past mental history. Um, and then they've got the drug history, the family history, social history. Um, and I just kind of remembered that as DFS, uh, like the sofa company which you may or may not have heard about. Um, so drug history, family history, social history, physical. It's kind of the last three, which I still got quite a bit of content in there. So you want to ask what if there aren't any medications. Um, and often when you say that people won't think of over the counter or herbal kind of supplements. Um, so you want to, uh, be able to ask about that as well as a specific question as well. This is really important this bit. Let's start it for you here. Um, drug allergies. That is like, that is a mark in your exams because if you do not ask about drug allergies and, you know, you, you say you're giving some kind of, um, uh, some kind of penicillin for a chest infection and the person got a drug allergy, that's, that's a massive, uh, impact on patient safety right there. So this is like one of the best and most important questions to ask. It's about any allergies, um, even other allergy as well because patient's may have uh an allergy to something like latex, which is used a lot in gloves, which you might use. So make sure you always very, um, kind of forward in asking that question and making sure you ask that question. Um, and this kind of links quite nicely. Well, uh in with kind of the e in Socrates. So the exacerbating or leaving. Um, so sometimes you might ask them whether they've tried anything for the pain or whatever symptom is, uh, they might say, okay, yes, I'm taking paracetamol for it and it hasn't helped. Um, and another thing to kind of impress the examiner, uh, again, going back to the allergies is what happens when you take that medication. So, um, for some people, they might get kind of a bit of tummy upset or kind of very small, um, rash which is not widespread and that's not really a true allergy, you know, uh, if someone says okay, I've had kind of anaphylactic shock and I've had difficulty breathing after taking this, then that's, uh, that's more likely to be a proper allergy. Um, so those kind of side effect type symptoms aren't really contra indications to giving, uh, drugs, but it should be noted and documented. And if someone says that then that's something you can mention when you're kind of summarizing your history. Yeah. Okay. And onto the family history, now, you want to make sure that you approach this in quite a sensitive manner because often, especially with the exams, they'll have something in there. Um that kind of tests your empathy. So you want to uh make sure that you demonstrate that. Um so you want to know what uh this kind of just a general good question to ask. Are there any medical conditions that were in the family? And then just depending on the presenting complaint, you want to be more specific. So for example, if someone come in with chest pain and you're thinking of something like a heart attack, you want to know whether there's any kind of history of heart problems within the family. Um And you can also find out the ages um which someone was diagnosed with the disease and also um um the ages with which. So for example, their parents might have died um from something like a heart attack because that can give you idea of some of these kind of genetic conditions. Um And from that, you can get an idea of what the patient is, is presenting with. And as I mentioned, it's a good, a good place to show the examiner how empathetic you are. Because when you're asking questions about these, they'll often have an answer that says um yes. Uh you know, my father passed away at age 50. Um And you want to be really sensitive about how you approach that. Um And the examiner will often be kind of watching response. So make sure you're kind of able to deal with that and you approach it sensitively uh and let the patient gonna have a moment and say, you know, okay, I'm sorry to hear that uh or something, some kind of something to that effect. Uh in terms of the social history, which is uh an imperial favorite. They love asking questions about this. Um And they have kind of, there are, is quite a lot to cover, but as long as you cover the main points, um you should be okay. So the main kind of three your smoking, alcohol and recreational drugs, um you can also have uh asked questions about occupation and stress um living circumstances because um for example, like housing, poor quality housing could lead to as damp, um could exacerbate someone's kind of asthma symptoms, exercise tolerance if they've kind of presented with any kind of uh, thing which, uh, pain or breathlessness, which gets worse with exercise. You want to know how, how has that changed? So, you're able to exercise a walk, I don't know, half a mile, uh, you know, two weeks ago, but are you only able to walk 100 m? Um, and A D L s which stands for activities of daily living. So, shopping, cleaning, cooking, uh, eating, uh, and you also want to ask, you can a question you can ask to kind of get an idea of their diet is, can you take me through a day, a typical day's food and drink? And that's just a nice question to kind of get, uh, uh, in response to that. And you can also ask about sleep. But as I said, the main, uh, three are smoking, alcohol, recreational drugs. So, with smoking, um, you want to say, ask whether, uh, whether they currently smoke and if so you want to quantify that, uh, impact years. Um, so a pack would be, uh, one pack years, 20 cigarettes a day for, for a year. Um, so, so if it was 10, if it was half bad, then you'd have half a pack year if it was for a year. Um, and also if they say, uh, once you've asked them, how do they smoke, if they say no, you want to ask them whether they've ever smoked, um, to get an idea of, because they might have something like a 30 pack year history. Do you want to get an idea of what's going on there in terms of alcohol? You want to ask them how much they drink, um, and more sensitive way to approach this is to start off with. Do you drink alcohol? They'll probably say yes. Um, and then you'll say okay, how could you take me through how much you drink in a week? Um, because it can be quite sensitive for some patient's being probed about the alcohol intake. Um And again, with the occasional drugs is quite sensitive one. Um So in the beginning, uh ideally, you would have as part of your introduction, you also want to say, um that everything you say would be confidential within the medical team. Um And that's, that's something you could re emphasize here uh before you kind of uh asked about recreational drugs. Um But also, like, don't be too shy about asking this so that you can try and sign post because they have direct sign opponent posting. But if you can't, if you just kind of go in um sensitively but kind of more in a more direct way, then it's, you know, it's still kind of okay. Um But it's just about not being too kind of bold. Uh If that makes sense. I mean, again, with a lot of these things, they'll come, the more you practice with people with your friends with an actual, with actual patient's um the more these kind of skills will come and this this session will just kind of give you an overview of what to kind of go through. Another thing you can think of is uh any recent kind of travel. This is especially relevant when someone's kind of got a chest pain or swelling in their leg. Because then you're thinking of something like a deep vein thrombosis or a pile of pulmonary embolism, which can be associated with the kind of uh long flight, uh prolonged immobility. So these are kind of really important uh factors which can influence what you're thinking in terms of your differential. Um They've also got a picture of, I've got a picture of a bird here because it's the more niche thing. But um, if they keep birds, then they, they can be predisposed um to like a certain type of pneumonia. But I wouldn't worry. But at this stage, I wouldn't worry too much about that. Um Okay. So in terms of how to ask questions, as I said, don't, uh don't try and launch straight in with you do drugs. Um But a lot of this is also also to do with your tone. Um So if your tone is kind of really appropriate, um then in some, some some circumstances, it could be okay, but the better thing to do is to always sign post and as I said, don't make that, make specific parts a big deal. Um you can, some people say, oh, I ask these, you know, we have to ask these questions to everybody. Um, and, and that's kind of an optional thing to do. Um, some people, some doctors don't like that. Some do. Um, so I wouldn't make a big thing of that. Um, don't make any assumptions. So you want to make sure when you're asking about occupation, you want to ask if they are working and then to follow up from there, not saying not to say okay, what's your job or what do you do for work? Um And you don't want to make any assumptions about their living situations or their partners. So a good way to kind of get uh information on it, kind of who's at home with them is just just to ask, is there anyone at home with you? Okay. Now, this is ice, which I'm sure a lot of you would have been aware of. Uh I've heard of so much already. Um So this idea is concerns and exploitations. Um A lot of people put this kind of towards the end of the history. Um I've kind of include that in this order here. Um It's about kind of what works, works best for you. So I personally wouldn't include it at the end. I would include it just after the history of presenting complaint because in there, they'll often say something I'm worried about this and you can't kind of explore that within here. Um And this is a kind of a really key marking point because they can literally give you like a mark for each of these. Um And it's a really big thing, but you don't want to ask it in a robotic way. Um And you don't also want to say, you know, what's your ideas, what your concerns, what's your expectations, you want to try and use that a bit different uh slightly different language. Um So you can say, oh um you know, um do you have any thoughts about what might be causing this? For example, um uh in terms of, in terms of addressing the concerns, you can say, um what are you worried this might be um or how is this kind of affecting you? Uh And in terms of expectations, you can a nice question to say is um and what are you hoping to get out of the consultation today or something like that? Um So you want to make sure that you don't ask it in a robotic way, but you want to also make sure that you've covered it. Um Because if you don't cover it, that's, you've lost a few marks there and it's, you know, it's something that's not particularly difficult to ask. Um It's got a nice acronym and you can remember, hopefully you can remember quite well. Um So just yet, always don't forget to ice the patient. Okay. So for the CPA last year they didn't say that we had to do a systems review. Um but that might change this year. Um So always kind of remember to read the poster that's outside station. Um And he's just kind of some examples of questions you can ask relevant to the presenting complaint. So for example, if they've got, um you know, it's a limb weakness. Um Someone pointed to the limb weakness, um that would be a kind of neuro neurological condition. Then you can ask about headaches. Um, any sensation changes, um, any loss of consciousness as well. Um If someone's had something like chest pain or um, breathlessness, you can ask them about uh syncope, which is a fainting dystonia, which is shortness of breath, a chest pain and cough. So, because that's a kind of a respiratory that symptom there. If they've got a gi problem, you can ask them about, about how frequently they, their bowels. Um And if they've had any abdominal pain, uh if they've uh noticed any change in bowel habit. Um And then again with your, oh, um, so any lower urinary tract symptoms. So that's things like urgency frequency, needing to go to the toilet a lot and need them to go quite suddenly and any blood in the urine as well. Um And then there's a few other kind of things which I've just put here. So kind of any recent infections or illnesses, um, any skin changes or joint pains. Um So this is kind of what useful slide just to kind of go over. Um And just kind of memorize if you uh kind of symptoms which you could ask about if, if they ask you to in the exam. Um So does anyone feel brave enough to do a history? If not, we can kind of all do it together through the chat? I think that might be a bit easier for everybody. Um So say you've got uh someone who is presenting with abdominal pain. I don't want you to put in the chat. What questions you'd ask? What questions you'd ask this patient to say we've done the introduction. Um What questions you wanna ask? Yeah. So if you, if you just pop it in the chat, you can also I'm new. That's fine as well. What questions would you want to ask where they feel the pain? Yeah, absolutely. Um Good. Any others? There's quite a lot to ask but we'll go through, we'll go through a few. Okay. Where is the pain? Where when did it start yet? If you can describe the pain, any associated symptoms? Um And how bad the pain is? Yeah, good. And remember to when they, when you ask how bad the pain is, you want to say on a scale of 0 to 10 0 being and you wanna explain the scale because some might put zero is the worst. Zero is the best. So we want to explain zero is no pain. 10 is the worst of vaginal pain. Have they had this type of pain before? Yeah, absolutely. Any other questions do you want to ask? Okay. So I'm going to start asking, answering some of these questions. So, um as a kind of an example patient. So, uh the pain is uh in the, uh it's on my right side and it's kind of near my hip, near my hip. Um It's, I felt kind of a dull ache for a few days and then it's uh in the first uh since kind of, since the morning today, it's been really sudden pain in the right kind of lower region. I know I haven't had this pain before yet. You want to ask about the bowel movements. So now that I'm giving you a bit more information, what questions do you not ask? What do you think it could be? Also? It radiates? Yeah, absolutely. So, um, note the pain that I've had has been there, um, for a few days until suddenly got worse and Albert haven't gone anywhere else. Uh, what I'm doing here is they might ask you in at the end of the CPA um to give you, uh they might ask for some of your differential diagnosis or potential diagnosis. So that's why you want to be able to recognize cluster of symptoms to be able to diagnose. Um Or so, think about diagnosing a certain condition. Any other questions or thoughts about what this type of pain is being, might be. Any, any associated symptoms. Yeah. I've got a, uh, a fever, I've got this fever and this pain and the kind of the right lower bit my tummy. What do you think your am? Absolutely. I thought I was the one I was going for appendicitis. Um, so that's, that's very good. So, yeah, that's, people are always going to say, uh, in the textbooks that pain is in my right iliac fossa then might just wait to it. Well, might just say, oh, it's kind of near my hair ports, bought a bit of my tummy on the right. It's kind of, so you need to be able to introduce um that yourself, which, which you did, which is very good. Um And yeah, you might also, I don't know if anybody asked if any, what made it worse, what made it better? I know there were good. Yes, Louise did. You did good. Um So like if, but if something presses on it, then it, it feels worse. Um which is kind of a pattern of right iliac fossa pain is worse on pressing down. Yeah, it's indicative of appendicitis. So uh well done. Um So again with, with this history, you do the introduction. Who are your role? Confidentiality? Is it okay? So we've, we've kind of run through Socrates. They're mostly um and you can also do other, you can ask other kind of uh symptoms and, and do a bit of the systems review as well, which, uh, so these, these kind of things, which a bit more specific, which I'm not sure anybody asked about a change in bowel habits of blood in stool. Um, last bowel movement and the nausea and vomiting. And then you want to know the amount, um, dysphasia which is difficulty, um, on swallowing and our don't aphasia, which is pain on swallowing. Uh, and your floor symptoms. Have people heard of this, this acronym flaws? Cool. Just type in the chair if, if you have or haven't. Just. So I know. Okay. Um So this is basically a kind of a red flag or things like cancer, mainly kind of your, your main malignancies is it's kind of a cancer almost mini screening uh tool within the history. So you want to ask about uh fever lethargy. So kind of, are you feeling more tired than normal? Um A is appetite changes? So are you feeling kind of more hungry or if you check is that you've noticed a change in your appetite? Uh w is uh weight loss because that's a big kind of red flag uh for a lot of kind of malignancies uh s is um night sweats. So are they waking up kind of totally uh kind of soaked? Um And that's kind of indicative of something like a malignancy or something like TV uh in some cases as well. Um And also you want to ask other symptoms. So, you're because there's other systems though there's a urinary symptoms, um, uh, gynecological symptoms which even though you're in, uh, in year two, this won't be O L L was lethargy. So, basically feeling more tired than usual. Um, so if you're feeling a lot more kind of tired and, uh, you don't have any, any kind of energy of things, that's a sign that, um, something kind of more sinister could be going on there. Okay. Um So yeah, that's kind of your floor symptoms. Um And yeah, I always ask about kind of other symptoms and systems if you can. Um, so don't just get kind of to stuck on. Always got to be a gastrointestinal issue. It could be your really gynecological, it could be a manifestation of some other system. Um And there's no harm in, you know, if someone's coming with abdo pain to ask, you know, um, have you had any shortness of breath or chest pain or other? Um, there's no harm in asking that. Um, but just make sure you're able to kind of fit it in within the 11 minutes and again, that will come with practice. Um So we've gone through our past, going through a past medical history. If they have previous abdominal surgeries, they might have this thing called adhesions, which is basically a post surgical complication. Um That's the commonest cause of small bowel obstruction. Um That could be something like an SBA that comes up in your written exam. Um So that's worth bearing in mind and remembering. Um, and some sort, if you had a previous abdominal surgeries, they can rule out um, some conditions. Uh for example, if they've had an organ removed, um, it's unlikely to be a problem with, um, kind of more with that, with that organ unless it's to do with the surgery in terms of like when it, when it was moved, any effective complications or other complications afterwards. Um You can have certain drugs which can cause have certain effects. Um in terms of uh um you know, suppression, pancreatitis, constipation, um you can have certain conditions as well, which can be quite heavily associated in the family history so that there's, there's always benefit in asking about the family history because even if they say nothing, uh then at least you aren't, you've asked it and you've got a marking point. Uh and within the social history, uh you might see this um E T O H that's basically um uh kind of a medical abbreviation for alcohol use, um which is very relevant for chronic liver disease, pancreatitis. Um smoking as I'm sure many of you will be aware of massive risk factor um for lots of different types of cancer, not just lung cancer. Um Recently things the patient has eaten. Um So that's more in if you're thinking some kind of uh g eye infection. So something like gastroenteritis. Um, and with something like that, it's worth asking if anybody around them as ill as well because that gives you an idea. Okay. This person has probably got some kind of infection if other people around them have got it as well. Um, you want to ask about travel. So this particular relevance of, for something like in our infectious diseases. Um, so somebody like TB, um, uh, if they've traveled to an area, area where that's pandemic, um or other uh more lesion faces diseases, then that's worth asking about as well. Um Now we're just going to go through another kind of history on breathlessness. It's OK. We've done our intro again. How can we, what kind of questions would we ask someone who has presented with breathlessness? And it's a bit harder because this, this kind of another level up because it's not, it's not as simple as your kind of uh pain history. It's a bit more complicated to what questions would you ask? You just pop it in the chat uh or someone who's presenting with breathlessness and that, that's all they might say on the sheet outside the uh what's outside the station? See a few people of time. And um yes, this is a bit more advanced, but this is something that could definitely come up in as a and youtube. So, yeah, when did it start? Does something make better worse? Yeah. So, yeah, you're still using these, you're still using kind of Socrates as a base. So, when did it start? How long for have they had it before? Yeah, that, that last question is always a very good one to ask whether they've had something before. Um, because I can really, if they've had something before then, you know, in some cases you can go back into their history and have a look at it and see what it was and how it's treated that can, you know, I can seal the deal that can make your diagnosis for you. Yep. About family history, substituting of, yeah, cardiovascular disease because it could be, isn't, but ruthlessness isn't just something that could be a respiratory cause. Um You could have a cardiac cause from it as well. Any other associated symptoms. Yep. Cost chest pain, palpitations. Yeah, absolutely. You want to do your cardio rest up um Systems review as well? Um So that's good. I think we'll kind of move on now. Yeah, if they smoke. Yep. You do that within the, within the service of history now. Um a little bit later on Sunday. Um So yeah, you'd want to adapt Socrates to fit the breathlessness. So, as we've mentioned, when did it start? So if it's something acute, it could be a common embolism or pneumothorax if it's chronic, um you could have COPD or what kind of worsening asthma is it always there? Um And how, how would they describe it in their own? Was um, as well. And then as we said, what makes it worse or better? So, orthopnea, which is basically, um, when you lie down it gets worse. Um, and that's, uh, indicative of, um, a congestive heart failure. Um, it can be worse during the week which could indicate indicate kind of occupational exposure with their job. Um, and it can be worse in the cold or with, uh, animals or exercise, which can indicate as something like a, uh, an asthma, uh, asthma or kind of allergic, more allergic picture as well. Um, so these are the kind of, uh, associated symptoms which had kind of be matched up with their potential cause I won't, um, kind of dwell on this too much. But if you have any questions about it, then you can ask me, um, and if you fill in the feedback form at the end, then you'll be able to get the slides as well. Um, so moving on. Um, so you want to ask about if they've had, if they actually have a known malignancy. So say if they got something like lung cancer, that's very likely to be what's causing the breathlessness. Um, uh, or if they've got any other diseases, autoimmune diseases, if they've had previous surgery, it could be a complication of that. So you've got to think about that as well. Um, this is a kind of more asthma specific point is that if you have beta blockers, so something like propranolol, uh, atenolol, um, all the kind of all old, uh, drugs that ended on a low, um, their beta blockers and they can actually worsen asthma symptoms and generally are not prescribed with people to people last month. Although there are some exceptions. Um, and some medications can actually toxic to a certain organs. So, such as the lungs, uh, as we've said, I'm gonna ask about smoking, especially with something like a respiratory history. Uh But basically in every, in every station, in every history station you want to be asking about that. Uh And you can also ask about bathing history, which is a bit um newer, which is not as common uh to get in the club in exam scenario. Uh again, travel history. Um And then, as I said, with the birds, you can get a high horse called a hypersensitivity pneumonitis. Um So, in a more so in a respiratory history, I ask if you have any kind of pets, um that's the kind of respiratory history specific question. And again, occupational exposure. Um So whether they've got any uh kind of blown disease as a result of uh exposure to something like asbestos or fine silica or something like that. Um So in summary, we've kind of covered what the CPA might be like. We've covered the basic structure of the history. Hopefully, I've given you some tips along the way. Um And we've had to look at abdominal pain and we've had a look at breathlessness. Um And if you've got any questions, then please let me know. Otherwise, please, please, please get in this feedback form here and then you'll be able to get a copy of the slides afterwards. Um And you can review some of the things that we've covered today. Um So I hope that was useful. Um And yeah, please scan in, please uh scan the QR code or fill in the click on the link in a chair and uh give me some feedback. It would be useful to improve the series and help me know what I can do better. Yeah, thank you so much. Ran very, very useful to please do feel in the feedback just so that Iran has something to show for this and you can also improve on it next time as well be as critical as you can. And yeah, so I'm just gonna stop the recording now. And if you do have any questions, me and ran will stick around.